88 replies to this topic

[Gail's]

Buzzm1, I went on and read the very brief statement on the link you posted under the "catastrophic coverage " heading. It says once you reach that point, you pay very little for drugs. No clear definition of what they mean by "very little." Do you have any experience or thoughts on that phase?

[Buzzm1]

Buzzm1, I went on and read the very brief statement on the link you posted under the "catastrophic coverage " heading. It says once you reach that point, you pay very little for drugs. No clear definition of what they mean by "very little." Do you have any experience or thoughts on that phase?

In the catastrophic phase (Stage 4), for Medicare Part D plans, you will pay 5% of the prescription price.  Kaiser is an exception, unless they have changed for 2017, you pay $12 per refill in the catastrophic phase.  Kaiser is also an exception in that they have classified generic Imatinib as a Tier 2 drug, meaning that monthly refills are $15.  All TKI brand names are classified as Tier 5 drugs.  Kaiser doesn't have the $400 deductible like most plans, but they did raise their initial percentage from 25% to 33%.  Please check me on this (once I heard that generic Imatinib was rescheduled as a Tier 2 drug, I stopped reading).

 

For those on most Medicare Part D plans taking brand name TKI's, for 2017, once you have personally paid in just under $3,000, you should reach the Catastrophic phase.  

[shweflen]

I just received my 2nd months prescription for this year through ExpressScripts and the local Walmart pharmacy.  I am taking 3 - 100 mg imatinib pills each day.

 

date            total cost            I paid          total applied to 2nd phase    total applied to 3rd phase

 

1/24           $1593.82            $698.45                 $1593.82                        $698.45

2/27           $1593.92            $398.45                 $3187.64                      $1096.90

[Buzzm1]

thanks for the update shweflen ... and thanks for the layout; it should help us understand how Medicare Part D works for generic drugs.

[r06ue1]

Doesn't it seem completely ridiculous that I pay $10 (copay card) and those who are retired have to pay 30 to 60 times more than I do?  How anyone can support this corrupt system (the whole package) is entirely incomprehensible to me.  

[chriskuo]

Ironically, the introduction of Medicare Part D less than 15 years ago is part of the cause of high drug prices.  Before that very few seniors had drug coverage.  Now that they do, drug companies have few seniors as customers who have to pay the whole cost out of pocket while Medicare is barred from negotiating drug prices.

[Buzzm1]

From Pat:

 

For those that are interested - I just reviewed my Part D estimate on medicare.gov and the reality today as I picked up my second order.

 

To review: In February the retail price of 50 mg. Sprycel is $7797.99 and Humana was billed $$6483. 87.

I paid $2338.54, of that $400 was deductible and the plan paid $4145.33.

 

That agreed with with my first month estimate on medicare.gov which shows my deductible would be met and the donut hole would be reached.

 

Today I picked up my second month of Sprycel. According to medicare.gov I should have paid $1045.15 (this also includes my 10 mg. Lisinopril which is only a couple of bucks a month). The reality is I "only" paid $797.72 for the Sprycel (retail and billed amount was same as February).

 

According to the medicare.gov site I should have met catastrophic benchmark this month and the rest of the year I will pay about $350/month for Sprycel and Lisinopril. (This also includes the $17/mo. I pay Humana.)

 

This is much better than anticipated, I thought this month's payment from me would be much more.

 

I will keep you posted on the costs for April.

[Buzzm1]

Pat, calculating your payments

 

For February

$400 nondeductible of $6483.87

$825 = 25% of the next $3300 ($3700 of $6483.87)

$1113.54 = in donut hole, 40% of remaining $2783.87 of $6483.87

$2338.54 Total for Feb. purchase; TrOOP $2338.54 + $1391.93 = $3730.47; TrOOP remaining $1219.53

 

For March

$542.01 = 40% of $1355.03 remainder of donut hole 

$256.44 = 5% of $5128.84 catastrophic phase

$798.45 Total for March purchase; TrOOP $3730.47 + $542.01 + 677.52 + (256.44) = $4950 (+ $256.44)

 

For April through December:

5% of $6483.87 = $324.19/mo. catastrophic phase

 

Your out-of-pocket before you exited the donut hole were $2338.54 + $542.01 = $2880.55

You received out-of-pocket credits of $1391.93 and $677.52 discounts from mfr. = $2069.45

 

If you filled your Sprycel 50mg Rx for all 12 months, your total cost for the year would be:

$2338.54 + $798.45 + (10 X $324.19) = $6,378.89 for Sprycel 50mg that cost $77,806.44 

[hannibellemo]

Buzz,

 

That seems about right. I was disappointed when I got my current summary from Humana indicating I was not yet in the catastrophic phase (how often do we get to be disappointed by not being in a catastrophy?), then I realized the summary was only for the month of February and did not include my 2nd order. The Medicare.gov site did not make it clear that $2,000 of the donut hole would be covered by mfg. discounts. Seeing that in your accounting was a pleasant surprise!

 

Pat

[Gail's]

Hi buzzm,
Would you post Kaisers costs to you so far this year? Hope I didn't miss it somewhere.

[Buzzm1]

Hi buzzm,
Would you post Kaisers costs to you so far this year? Hope I didn't miss it somewhere.

Gail, my Kaiser Senior Advantage Plan costs $82/mo; $30/visit; lab tests are $35/visit regardless of the number of tests; I'm not currently on a TKI but if I was still on Gleevec, generic Imatinib would cost $15/monthly refill, as Kaiser has it scheduled as a Tier 2 drug.  My blood pressure drugs will cost me roughly $200 for the year.  

 

In regard to brand name TKIs and Medicare Part D, Kaiser doesn't have the $400 deductible, followed by 25% of the next $3,300; Kaiser instead now charges 33% of the first $3,700. In catastrophic phase Kaiser charges $12/monthly refill, rather than the 5% of cost that other plans do.

 

For 2018, the Medicare Donut Hole will be $3,750 to $5,000.

2018: 35% for brand-names and 44% for generics

Assuming Kaiser remains the same, and Mfr. credit is still 50% while in the donut hole, your Medicare Part D 2018 Sprycel 50mg Rx would cost:

 

Recalculated using 33% instead of 33.333%

$1,237.50 (33% of the first $3,750.00)

$1,549.26 of the next $4,426.47 (Mfr. 50% credit would be $2,213.24 during the donut hole)

$132.00 for the last 11 months of the year (in month 2 you would finish paying your way out of the donut hole + $12 catastrophic phase)

$2918.76 Total out-of-your-pocket for the year 

 

Hope this answers your questions.

[pammartin]

_{After my first month of the PH drugs, I pay very little the rest of the year.  That first shipment is over the donut hole we are obligated to pay.  I believe out of pocket is about $6000, but there are grants and programs to help with some of that initial cost.}

 

_{There used to be the same programs for the CML drugs, I am not sure they are still available.  I have been on Medicare for a year now and once I get through January, I am sitting pretty good for the rest of the year.}

 

_Pam

[chriskuo]

Pam,

 

How is the 5% copay in catastrophic phase covered?

[pammartin]

Chriskuo, currently there are excellent co pay programs for the PH meds, at least since I have been on them.  We who take them had a huge scare last fall because Caring Voice offered the supplemental co pay assistance and they simply disappeared.  Even the people who help others receive grants and co pay assistance were surprised. 

 

Thankfully with help I was directed to another assistance program and receive nearly the same benefits I did with Caring Voice.  My co pay for both the Letairis and the Adcirca are $20 per prescription, per month.  The cost for these meds compares to the CML meds, Nearing $10,000 a month. I would be paying out-of-pocket the donut hole cost if not for the assistance along with the 5%.

 

I take several other maintenance meds for different diagnosis and the 5% is usually less than $10.  

 

I do not want to take the conversation far away from the TKI topic but I ran into a frustrating situation concerning my Ambien. Last summer instead of getting the 10mg Ambien I requested 5mg, my physician simply wrote out a script for 60 - 5mg tabs instead of 30 - 10mg tabs.  In January the drug was denied. I have drove myself crazy trying to figure out how to get a drug approved. My physician sent two other scripts for comparable meds that were denied.  She put the ball in my lap stating I had to contact Humana to find out what formulary drug they would cover.  It took me over 2 months and about 40 calls between the pharmacy, physician, and Humana. After speaking with Humana more times than I wish to remember I finally found a person who clarified it was not the Ambien but the amount of pills.  Humana would not authorize 60 - 5mg pills because the pill count went over the allotment for the month, although it was the same mg.  They would authorize 30 - 10mg pills.  By the end of the day I had my script filled once again. Had I simply cut them in half when I did not believe I needed the full dose my med would not have been interrupted.  Took months for me to discover this.

 

My experience has me wondering about the future of drugs in general.  At one time it was only the mg that was important, especially with medications that are closely regulated like Ambien.  In this instance it was the number of tablets given per month. Ambien is prescribed in 10mg as the highest dose I believe, so the focus was not on the mg but the tablet.  When the insurance companies begin using both the mg and the # of meds given per month, it could become very difficult to receive an accurate dose of monthly meds.

 

Ok, I have rambled enough. 

 

Pam

[Dom]

Here's my first month experience with ExpressScripts and Walmart. I'll add to this thread each month until I hit catastrophic care.

Imatinib mesylate 400mg. (30 pills) Retail = $8,252.27. My share = $478.54
Imatinib mesylate 100mg. (60 pills) Retail = $4,940.19. My share = $265.73

[danno]

Just think, the Democrats say there is nothing wrong with Obamacare

[hannibellemo]

Just think, the Democrats say there is nothing wrong with Obamacare

I don't think that is a fair or correct statement, danno. The ACA is not perfect, I don't think anyone would say it is, but, as is obvious, this Congress is finding it's not so easy to find a better solution for insuring healthcare for all, that lawmakers, especially in this case, Republicans, can agree on.

[hannibellemo]

Dom,

 

I saw that you posted that Walmart (through Express Scripts) has the best prices for your generic Gleevec. That is true for Sprycel through Humana, too, as Humana has a special contract with Walmart. However, the difference was not great ($13.00) so I choose to use my regular HyVee pharmacy which is only 5 minutes from my house (and has my other 'scrips) compared to Walmart which is 20 minutes away. I figure my time has got to be worth something. I'll keep an eye on that in years to come though.

[shweflen]

date     total cost    I paid      deductible YTD       phase 2 YTD       coverage gap YTD

 

1/24      1593.82    698.45     400.00                    1593.82               698.45

2/27      1592.82    398.45                                    3187.69              1096.90

3/9            10.00      10.00                                    3197.69              1106.90

3/9            37.43      37.43                                    3235.12              1144.33

3/28       1593.82   691.96                                    3700.00              1836.29

 

In January I paid $400 deductible plus 25% of ($1593.82 - $400.00)

In February I paid 25% of $1593.82

In March, for two other generic drugs, I paid the total cost but their cost was credited to the phase 1 and coverage gap.

In March, for the imatinib, I paid 25 % of ($3700 - $3235.12) plus 51 % of the remainder in phase 2 which was $1128.94.

In April, May and June I expect to pay 51% of @1593.82

After that, for one month, I will pay 51% of whatever remains of the $4950 limit in phase 3 plus 5% of the rest of the total cost for that month.

Then, for the rest of the year, I will pay 5% of $1593.82.  I think.

[Buzzm1]

In April, May and June I expect to pay 51% of @1593.82

After that, for one month, I will pay 51% of whatever remains of the $4950 limit in phase 3 plus 5% of the rest of the total cost for that month.

Then, for the rest of the year, I will pay 5% of $1593.82.  I think.

shweflen, you are correct.  thanks for the update.